Gout + Pseudogout (CPPD) Flashcards
What is the primary cause of gout?
Deposition of monosodium urate (MSU) crystals in joints and soft tissues due to hyperuricemia
(high serum uric acid levels)
What are the main causes of hyperuricemia?
Increased urate production
= high purine diet, alcohol, enzyme defects, myeloproliferative disorders
Reduced urate excretion
= chronic kidney disease, diuretics, hypothyroidism
What is the most common site for acute gout?
The first metatarsophalangeal (MTP) joint
What is the typical presentation of acute gout?
(1) Severe
(2) sudden-onset pain
(3) hot swollen joint
(4) commonly affecting the MTP joint, (5) lasting about 10 days
(3 days with treatment)
How does chronic tophaceous gout present?
(1) Painless white accumulations of uric acid (gouty tophi)
(2) which can occasionally erupt through the skin
(3) often associated with diuretic use
What is the most sensitive test to diagnose gout during an acute attack?
Aspiration of synovial fluid showing needle-shaped, negative birefringent crystals under polarised microscopy
What is the first-line treatment for acute gout?
NSAIDs (eg, naproxen), unless contraindicated by renal impairment
What is the second-line treatment for acute gout?
Colchicine
= especially for patients with heart failure or chronic kidney disease.
What is the third-line treatment for acute gout?
Steroids
What is the recommended prophylaxis for gout after an acute attack?
Start 4-6 weeks after the acute attack with allopurinol (or febuxostat if allopurinol is not tolerated) along with NSAID cover to prevent exacerbation
What are the indications for prophylactic therapy in gout?
- Two or more acute attacks despite lifestyle modification
- Presence of gouty tophi
- Heart failure when unable to stop diuretics
What is the target serum uric acid level for gout prophylaxis?
300-360 µmol/L, monitored every 4-6 weeks
What does polarised light microscopy of synovial fluid reveal in gout?
Negatively birefringent, needle-shaped crystals
What does polarised light microscopy of synovial fluid reveal in pseudogout?
Positively birefringent, rhomboid-shaped crystals
What is the management of acute gout in renal impairment?
Steriods
What is podagra?
Gout affecting the great toe MTP
What joints can be affected in gout?
Ankle, foot, hand, wrist, elbow and knee
A 62-year-old male presents to his GP with a hot, swollen and painful knee. His past medical history includes diabetes, hypertension and a previous duodenal ulcer. His drug history includes ramipril, amlodipine, metformin and indapamide. His observations are normal.
Given the likely diagnosis, what is the most appropriate initial management and why isn’t it NSAIDS
Colchicine
= patient has previous peptic ulcer
A patient presents with sudden severe pain, redness, and swelling in the first metatarsophalangeal joint. What investigation would confirm the likely diagnosis?
Synovial fluid analysis
A 67-year-old male presents to his GP with an acutely painful, hot, red, swollen left 1st metatarsophalangeal (MTP) joint. He had experienced a similar episode 6 months previously.
Given the likely diagnosis, what is the mechanism of the preventative medication he is expected to be prescribed?
Xanthine oxidase inhibitor
A 70-year-old patient presents with an acutely hot, swollen and painful right wrist. Further examination reveals concurrent hepatomegaly, scarring over the antecubital fossa and pinprick marks over his fingertips.
Given the likely diagnosis, what is the most likely finding on joint aspiration?
Positively birefringent rhomboid-shaped crystals
= pseudogout
A 65-year-old man presents with sub-acute onset ankle pain and swelling. His past medical history includes hypertension (for which he takes lisinopril, amlodipine and indapamide) mild COPD (for which he takes PRN salbutamol and regular seretide) and G6PD deficiency.
On examination, the skin is red and swollen around the right ankle and exquisitely tender to touch. Observations are normal.
What is the most likely diagnosis?
Gout
A 68-year-old gentleman presents to his general practitioner with a painful left big toe. He is diagnosed with gout and prescribed a course of 5 days of colchicine along with allopurinol. His other medications include ramipril, bendroflumethiazide, citalopram and aspirin. After starting treatment his pain becomes more severe.
What is the most likely to be the cause of his symptoms worsening and explain why?
Starting allopurinol
= allopurinol is the chronic preventative treatment for gout flares, it should not be started during an acute flare
Risk factors of pseudogout include what?
- osteoarthritis
- trauma
- hyperparathyroidism
- haemochromatosis
- electrolyte imbalances
What is the first-line treatment for acute gout attacks?
NSAIDs (eg, naproxen)
What is the first-line treatment if NSAIDs are contraindicated in acute gout attacks?
Colchicine
What is the first-line treatment for chronic gout attacks?
Allopurinol
Why are NSAIDs added when starting allopurinol for gout treatment?
NSAIDs are added to cover potential gout flare-ups that may occur when allopurinol is first started, as rapid lowering of uric acid levels can trigger an acute attack
A 60-year-old man presents to his GP with worsening painful swelling of his left toe, which is red and hot to the touch. He has a past medical history of IBS, hypertension and angina, for which he takes ramipril, bendroflumethiazide and bisoprolol. He is afebrile and otherwise systemically well.
Given the likely diagnosis, what is the most appropriate management?
NSAID
A 67-year-old woman presents to the Emergency Department with a severely swollen right ankle and no history of trauma. She is a type 2 diabetic and mentions there is a family history of rheumatoid arthritis. Observations are normal.
On examination, her ankle was red, swollen, and more painful when moving. Joint aspiration was performed, and synovial fluid was sent for microscopy, culture, and sensitivity testing.
Which features would be consistent with the most likely diagnosis?
Needle-shaped crystals
What is the second-line preventative treatment for gout when allopurinol is not tolerated and lifestyle measures have failed?
Febuxostat
Well-defined “punched-out” erosions and subchondral sclerosis are features characteristic of what?
Recurrent gout
A 65-year-old male attends his GP surgery with a hot, swollen and painful right ankle that developed overnight. His temperature is 37.9C and his other observations are normal. His ankle is extremely painful to touch. He has a past medical history of hypertension and MI and takes indapamide, ramipril, aspirin and simvastatin.
What investigation findings would be supportive of the most likely diagnosis?
Joint fluid aspirate polarised light microscopy shows negatively birefringent needle-shaped crystals
A 58-year-old gentleman presents with excruciating pain in his left toe. Passive movement results in pain and he says it is too painful to have a blanket covering his toe joint. He is a teetotaller and has never had this pain before. He has been having back pain and has been taking NSAIDs regularly as a result, he was discharged 1 week ago following a hospital stay of a few days following a gastric ulcer bleed. On examination, there was evidence of florid synovitis of the joint with extreme tenderness.
Given the diagnosis, what is the most common side effect to warn him about regarding the most appropriate treatment for his condition?
Colchicine would be the treatment
= side effect is diarrhoea
You are an FY1 in A&E and you are asked to see a 58-year-old gentleman with excruciating pain in his left toe. Passive movement results in pain and he claims it is too painful to have a blanket covering his toe joint. He denies any trauma. He has a known history of chronic kidney disease and is on haemodialysis with an eGFR of 5. The registrar performs a joint aspiration and asks you to start basic management.
What is the most appropriate medication to treat this patient with?
Steriods
A 65-year-old patient with a history of chronic tophaceous gout, diabetes mellitus, chronic kidney disease and hypertension presents to the emergency department with painful skin lesions and feeling very unwell for the past 24 hours. On examination, the affected skin appears erythematous and blistered. A few lesions have ruptured and started to peel off. He was started on a new medication last week by his doctor.
What medications may have contributed to his symptoms?
Allopurinol
= can cause rashes, allergic reactions Stevens-Johnson syndrome
When can allopurinol be started in gout?
- Recurrent attacks
- Presence of tophi or renal stone
- Allpurinol is only started 2-3 weeks after the gout episode has resolved.
When are NSAIDs contraindicated?
warfarin, peptic ulcer disease, heart failure, renal imparemnet
What is the pharmacological management for acute gout?
First line - NSAIDs.
Second line - colchicine.
Third line - steroids
What needs to be started alongside allopurinol in gout?
NSAID or colchicine cover has to be introduced for 3 months
What is the management of acute gout in a patient with a high risk of gastrointestinal side effects, CKD or heart failure?
Colchicine
A 60-year-old man presents to A&E with a two-day history of severe pain, redness, and swelling in his right big toe. He has a history of chronic kidney disease (eGFR 45 mL/min/1.73m²) and hypertension and takes lisinopril and hydrochlorothiazide. He reports a recent episode of diarrhoea and vomiting, treated with antibiotics two weeks ago, but denies trauma or other recent illnesses.
On examination, the affected toe is warm, erythematous, and tender to the touch, with no signs of systemic infection. Laboratory tests show a mildly elevated white blood cell count. Joint aspiration reveals an inflammatory synovial fluid, but there are no organisms present on Gram stain.
What is the most appropriate management for this patient?
Colchicine
= acute attack
What causes pseudogout?
Deposition of calcium pyrophosphate crystals in joints and soft tissues
What joints are most commonly affected in pseudogout?
wrist, knee
What is the key difference between gout and pseudogout in terms of crystal deposition, and how does this affect the ankles?
Type of crystals deposited:
1. gout involves monosodium urate crystals
- pseudogout involves calcium pyrophosphate crystals
What is chondrocalcinosis in the context of pseudogout?
(1) Refers to the deposition of calcium pyrophosphate in cartilage and other soft tissues without acute inflammation
(2) Often seen in elderly patients
How is pseudogout diagnosed?
Diagnosis is confirmed by synovial fluid aspiration showing
(1) calcium pyrophosphate crystals
(2) positively birefringent
(3) rhomboid in shape
What are the common symptoms of pseudogout?
(1) monoarthritis with a swollen, painful, and warm joint.
(2) The knee is the most commonly affected joint
How is gout differentiated from pseudogout microscopically?
- Negatively bi-refringent crystals are diagnostic of gout
- Positively bi-refringent ‘rods’ are diagnostic of pseudogout
A 54-year-old gentleman presents with a swollen and painful right shoulder. He is currently being investigated for deranged liver function tests and has recently been diagnosed with type 2 diabetes. The shoulder is tender to touch and warm, and there is a restricted range of movement attributable to the pain. No other joints are involved. His temperature is 36.9°C.
X-ray of the right shoulder shows chondrocalcinosis and joint space narrowing.
What is the most appropriate management plan?
Needle aspiration of the shoulder joint
A 60-year-old man who is currently being treated in hospital for community-acquired pneumonia develops a swollen, painful right knee. He has a background in haemochromatosis and type 1 diabetes. On further questioning, the patient says he fell a few days ago and wonders whether this could have caused his symptoms. He has a knee x-ray which shows chondrocalcinosis and no fractures.
What is the most likely diagnosis?
Pseudogout
How should acute pseudogout be treated and is prophylactic treatment recommended?
Acute pseudogout
(1) Needle aspiration to exclude sepsis (2) NSAIDs, colchicine, steroids, and rehydration.
Chronic
= None
What blood tests are commonly seen in pseudogout?
- Rise in inflammatory markers
- High serum iron
What conditions are associated with pseudogout?
(1) hyperparathyroidism
(2) hypothyroidism
(3) hypophosphataemia
(4) haemochromatosis
(5) Wilson’s disease
What are the joint X-ray findings in pseudogout?
- Chondrocalcinosis
- Changes for osteoarthritis
(LOSS
= Loss of joint space, Osteophytes, Subarticular sclerosis, Subchondral cysts).
